- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $9,772.37 / $14,125.38
| Facility | | $3,801.89 | $9,772.37 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $2,137.96
| Professional | | $676.08 | $954.99 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $3,162.28
| Professional | | $1,819.70 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $3,801.89 / $10,232.93
| Facility | | $676.08 | $3,801.89 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,238.72 / $3,890.45
| Professional | | $1,380.38 | $2,238.72 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,019.95 / $4,265.80
| Professional | | $2,344.23 | $3,019.95 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,380.38 / $5,011.87
| Facility | | $676.08 | $1,380.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $1,000.00 / $2,454.71
| Professional | | $60.26 | $1,000.00 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,951.21 / $4,265.80
| Professional | | $851.14 | $2,951.21 | $4,265.80 |